0099-2399/86/1207-0315/$02.00/0 JOURNALOF ENDOOONT~CS Copyright 1986 by The AmehcanAssociationofEndodontists Printed in U.S.A. MOL. 12, NO. 7, JULY 1986 A New Treatment Modality for Internal Resorption David Eugene Stamos, DDS, and Daniel George Stamos, DDS, MS A new treatment modality is offered for internal resorption. Two case reports are described. The Cavi-Endo ultrasonic unit with 2.6% sodium hypo- chlorite was used for canal preparation and preflar- ing. After final canal preparation, a #20 ultrasonic file was placed back into the canal and activated with intermittent irrigation for an additional 3 min. The Obtura injection-molded thermoplasticized gutta-percha delivery system was used to obturate the canal. Vertical condensation was used to com- pact the gutta-percha. Bell (1) first described a tooth having internal resorption in 1830. Since that time, there have been numerous reports in the literature concerning various aspects of treatment but there has been very little change. Now with the recent introduction of the ultrasound instru- mentation and injection-molded thermoplasticized gutta-percha obturation techniques, a new treatment modality is offered. Instrumentation of canals with internal resorption has consisted of mechanical and chemical debridement. Morphologically, these root canals exhibit many com- plex irregularities (i.e. fins and cul-de-sacs). It has been shown by Gutierrez and Garcia (2) that prolongation of the root canals, resembling fins, were never touched by root canal instrumentation. Shih et al. (3) reported that irregularities in the main canal may contain organic tissue not mechanically removed. Chemical debride- ment of these canals has been relied on exclusively. However, Senia et al. (4) found that 5.2% sodium hypochlorite, when combined with usual hand instru- mentation, was not effective in removing debris from the apical third of the canal. Richman (5) in 1957 first described a root canal preparation technique utilizing ultrasonic energy. Some 20 yr later, Martin (6) further investigated the use of ultrasound for the disinfection of the root canal system in combination with a bactericidal irrigant. He concluded that ultrasound in conjunction with a bactericidal irrigant was effective in achieving a greater reduction in organic debris and microorganisms than ultrasound alone with a neutral buffer solution. Cunningham et al. (7), in an 315 evaluation of root canal debridement comparing con- ventional instrumentation and ultrasonic instrumenta- tion, found that canals debrided by the ultrasonic tech- nique were significantly cleaner at all canal levels stud- ied. This was supported by a scanning electron micro- scopic study which reported that canals instrumented by ultrasonics were significantly cleaner than those instrumented conventionally (8). Obturation of canals with internal resorption has been achieved with semisolid materials, with the warm gutta- percha method being used most frequently (9). Yee et al. (10) studied the obturation of root canals using injection-molded thermoplasticized gutta-percha in 1977. He found that the injection-molded technique leads to a seal comparable to that of conventional techniques. Torabinejad et al. (11), in a scanning elec- tron microscopic study, further supported this finding. Marlin et al. (12), in a preliminary report, described clinical success rates comparable to the rate achieved with conventional gutta-percha obturation techniques. The purpose of this article is to report two cases of internal resorption that were treated with ultrasonics and injection-molded thermoplasticized gutta-percha. CASE 1 A 37-yr-old white male was referred to the graduate department at Marquette University for endodontic therapy. The medical history was noncontributory. A past history of trauma to the maxillary anterior region was reported by the patient. No response could be elicited from tooth 7 using the electric pulp tester or a carbon dioxide cold test. The remaining anterior teeth all responded within normal limits. Radiographic ex- amination revealed internal resorption in tooth 7 (Fig. 1). A diagnosis of pulpal necrosis with a normal peri- apical region was established and the patient con- sented to endodontic therapy. Standard endodontic access was prepared under rubber dam isolation. A #15 file was the first instrument felt to bind and a working length of 27.0 mm was established. Canal preparation and preflaring was ac- complished using a 2.6% solution of sodium hypochlo- rite and the Cavi-Endo (Dentsply International, Inc., York, PA) ultrasonic unit as described by Stamos et al.
Transcript
0099-2399/86/1207-0315/$02.00/0 JOURNAL OF ENDOOONT~CS Copyright�9 1986 by The Amehcan AssociationofEndodontists
Printed in U.S.A. MOL. 12, NO. 7, JULY 1986
A New Treatment Modality for Internal Resorption
David Eugene Stamos, DDS, and Daniel George Stamos, DDS, MS
A new treatment modality is offered for internal resorption. Two case reports are described. The Cavi-Endo ultrasonic unit with 2.6% sodium hypo- chlorite was used for canal preparation and preflar- ing. After final canal preparation, a #20 ultrasonic file was placed back into the canal and activated with intermittent irrigation for an additional 3 min. The Obtura injection-molded thermoplasticized gutta-percha delivery system was used to obturate the canal. Vertical condensation was used to com- pact the gutta-percha.
Bell (1) first described a tooth having internal resorption in 1830. Since that time, there have been numerous reports in the literature concerning various aspects of treatment but there has been very little change. Now with the recent introduction of the ultrasound instru- mentation and injection-molded thermoplasticized gutta-percha obturation techniques, a new treatment modality is offered.
Instrumentation of canals with internal resorption has consisted of mechanical and chemical debridement. Morphologically, these root canals exhibit many com- plex irregularities (i.e. fins and cul-de-sacs). It has been shown by Gutierrez and Garcia (2) that prolongation of the root canals, resembling fins, were never touched by root canal instrumentation. Shih et al. (3) reported that irregularities in the main canal may contain organic tissue not mechanically removed. Chemical debride- ment of these canals has been relied on exclusively. However, Senia et al. (4) found that 5.2% sodium hypochlorite, when combined with usual hand instru- mentation, was not effective in removing debris from the apical third of the canal.
Richman (5) in 1957 first described a root canal preparation technique utilizing ultrasonic energy. Some 20 yr later, Martin (6) further investigated the use of ultrasound for the disinfection of the root canal system in combination with a bactericidal irrigant. He concluded that ultrasound in conjunction with a bactericidal irrigant was effective in achieving a greater reduction in organic debris and microorganisms than ultrasound alone with a neutral buffer solution. Cunningham et al. (7), in an
315
evaluation of root canal debridement comparing con- ventional instrumentation and ultrasonic instrumenta- tion, found that canals debrided by the ultrasonic tech- nique were significantly cleaner at all canal levels stud- ied. This was supported by a scanning electron micro- scopic study which reported that canals instrumented by ultrasonics were significantly cleaner than those instrumented conventionally (8).
Obturation of canals with internal resorption has been achieved with semisolid materials, with the warm gutta- percha method being used most frequently (9). Yee et al. (10) studied the obturation of root canals using injection-molded thermoplasticized gutta-percha in 1977. He found that the injection-molded technique leads to a seal comparable to that of conventional techniques. Torabinejad et al. (11), in a scanning elec- tron microscopic study, further supported this finding. Marlin et al. (12), in a preliminary report, described clinical success rates comparable to the rate achieved with conventional gutta-percha obturation techniques.
The purpose of this article is to report two cases of internal resorption that were treated with ultrasonics and injection-molded thermoplasticized gutta-percha.
CASE 1
A 37-yr-old white male was referred to the graduate department at Marquette University for endodontic therapy. The medical history was noncontributory. A past history of trauma to the maxillary anterior region was reported by the patient. No response could be elicited from tooth 7 using the electric pulp tester or a carbon dioxide cold test. The remaining anterior teeth all responded within normal limits. Radiographic ex- amination revealed internal resorption in tooth 7 (Fig. 1). A diagnosis of pulpal necrosis with a normal peri- apical region was established and the patient con- sented to endodontic therapy.
Standard endodontic access was prepared under rubber dam isolation. A #15 file was the first instrument felt to bind and a working length of 27.0 mm was established. Canal preparation and preflaring was ac- complished using a 2.6% solution of sodium hypochlo- rite and the Cavi-Endo (Dentsply International, Inc., York, PA) ultrasonic unit as described by Stamos et al.
316 Stamos and Stamos Journal of Endodontics
FIG 1. Maxillary right lateral incisor, preoperative radiograph. Note internal resorption. Maxillary central incisor has unusually wide pulp chamber. Defective distal and facial resins are present.
(13). After final canal preparation, a #20 ultrasonic file was placed back into the canal and activated with intermittent irrigation for an additional 3 min. The canal was obturated during the same visit using a zinc oxide- eugenol sealer and an injection-molded thermoplasti- cized gutta-percha delivery system (Obtura, Unitek Cor- poration, Monrovia, CA). Vertical condensation was used to compact the gutta-percha firmly. Cotton and Cavit were placed in the access opening and a post- operative radiograph was taken (Fig. 2). The patient returned in 1 yr for a recall examination and reported no symptoms. Radiographic examination showed a normal periapical bone pattern (Fig. 3).
CASE 2
A 32-yr-old white male was referred to the graduate department at Marquette University for endodOntic therapy. This medical history was noncontributory. Eight years previously the patient had a bicycle accident with a resulting crown fracture of tooth 7. A porcelain veneer crown was placed and the patient remembers no further problems. For the past year the patient has noticed a raised area over tooth 7 with an occasional discharge. Clinical examination revealed a draining sinus tract over tooth 7. The tooth responded to carbon dioxide cold testing. A radiograph was made with the
FIG 2. Postoperative radiograph. Canal obturated using Obtura gun.
FIG 3. Radiograph 1-yr posttreatment.
Vol. 12, No. 7, July 1986 Internal Resorption Treatment 317
the paste, and the canal was sealed with Cavit and the crown was replaced (Fig. 5).
The patient was seen 7 wk later, at which time a radiograph was made and the crown removed to check the condition of the Ca(OH)2. The sinus tract over tooth 7 had disappeared and the Ca(OH)2 was dry. The radiograph showed that some of the Ca(OH)2 had been absorbed on the mesial surface. It was decided to replace the crown without changing the Ca(OH)2.
Six months after the initial appointment, the Ca(OH)2 dressing was removed. Paper points showed the canal to be dry. The Neosono-D (American Medical & Dental Corp., Cherry Hill, N J) was used to check for leakage from the resorbed area on the mesial surface of the root. This was accomplished by bending the tip of a #15 file and gently exploring the perforated area while connected to the Neosono-D. The digital read-out indi- cated leakage present from the perforation even though a slight resistance was felt. Ca(OH)2 was repacked into the canal and the crown was replaced.
The patient returned 4 months later, at which time the crown was removed and the Ca(OH)2 taken out. Paper points again were dry and use of the Neosono- D indicated minor leakage from the mesial surface. It was decided to obturate the canal at this visit. Obtur-
FIG 4. Maxillary right lateral incisor, preoperative radiograph. Sinus tract traced to mesial surface using gutta-percha. Note area of perforated internal resorption.
sinus tract being traced with a gutta-percha cone (Fig. 4). The radiograph revealed considerable internal re- sporption, with lateral root perforation on the mesial surface. A diagnosis of irreversible pulpitis with sup- purative periodontitis was established, and the patient consented to endodontic therapy.
The area was infiltrated with local anesthetic and the crown was removed for easier access. Standard en- dodontic access was made under rubber dam isolation. Profuse hemorrhage from the canal was encountered. A #20 file was the first file to bind at a working length of 19.0 mm. The canal was hand instrumented to a #25 and closed with cotton and Cavit. The crown was replaced with temporary cement.
One week later the patient returned. The Cavi-Endo ultrasonic unit with 2.6% sodium hypochlorite was used for canal preparation and preflaring. A #20 ultrasonic file was placed into the canal and activated for an additional 3 min with intermittent irrigation. The last hand file to reach working length was a #50 file. A thick paste of Ca(OH)2 (Lilly, Indianapolis, IN), barium sulfate (10%), and 2% lidocaine with 1:100,000 epi- nephrine was packed into the canal with an amalgam carrier and various condensers. Cotton was placed over
FIG 5. Working radiograph with canal packed with calcium hydroxide and barium sulfate.
318 Stamos and Stamos Journal of Endodontics
FIG 6. Postoperative radiograph. Canal obturated using Obtura gun. Note second area of resorption on distal.
ation consisted of a Ca(OH)2 sealer (Sealapex; Kerr, Romulus, MI) and an injection-molded thermoplasti- cized gutta-percha delivery system. Vertical conden- sation was used. Cotton and Cavit were placed in the access and the crown replaced with temporary cement. A postoperative radiograph was made (Fig. 6). The patient returned in 7 months for evaluation, at which time he was asymptomatic. Radiographic examination revealed good periapical healing (Fig. 7).
DISCUSSION
A multiplicity of uses for ultrasonics has been previ- ously described by Stamos et al. (13). Internal resorp- tion was not discussed and only Chivian (14) has made any reference to ultrasonics for use in such cases. Ultrasonics is effective because of a synergistic action involving both physical and chemical activity. Physical activities associated with ultrasonics include cavitation and acoustic streaming. Cavitation refers to the growth and collapse of small bubbles in a fluid medium causing radiating shock waves. These waves produce a very effective cleansing mechanism in irregular canal spaces. Acoustic streaming is the harmonic motion of the irri- gant around the energized file enhancing removal of debris. Chemical activity is associ'&ted with ultrasonic
FIG 7. Radiograph 7 months posttreatment.
activation of a bactericidal irrigant. It has been shown that ultrasonic activation of 2.6% sodium hypochlorite warms the solution, an action that will improve its tissue dissolving ability (15). Ultrasonic activation also will enhance the disinfecting capability of sodium hypochlo- rite in root canals (6). These synergistic effects enable the irrigant to cleanse and penetrate the canal space. In the cases presented, an additional 3 min of intermit- tent irrigation was used to maximize the chemical effect of the energized irrigant. In a study comparing conven- tional and serial instrumentation, the results showed the canal to be clean only where instrumentation had occurred (16). It has recently been shown that canals prepared with the step-back/ultrasonic technique are significantly cleaner than canals treated with the con- ventional step-back technique (17). This was attributed to the action of the ultrasonically activated irrigant within the canal system.
Obturation of canals with internal resorption has been quite a challenge in the past. The warm gutta-percha method has proven to be the most effective technique in producing a three-dimensional root fill. Thermoplas- ticized injection-molded gutta-percha has. been shown to given an impression-like reproduction of the irregu- larities of the root canal space (10). Vertical condensa- tion was used in both cases to ensure a dense root fill. Sealer is advocated not only for a hermetic seal but
Vol. 12, No. 7, July 1986
also to act as a lubricant for the gutta-percha. Long- term follow-up is necessary to determine endodontic Success.
SUMMARY
Two cases were presented involving internal root resorption. A new treatment modality involving ultra- sonics and injection-molded thermoplasticized gutta- percha was described.
We are grateful to our late father, James A. Stamos, for his enthusiasm and support in our endeavors. We wish to thank Kathryn Scheets for her assistance in preparation of this article.
Dr. David Stamos is currently a second-year endodontic graduate student at Marquette University School of Dentistry. Dr. Daniel Stamos is a recent graduate and is currently in private practice in Kansas City North, MO.
References
1. Bell T. The anatomy, physiology, and disease of the teeth. Philadelphia: Carey and Lee Publishing, 1830:171.
2. Gutierrez JH, Garcia J. Microscopic and macroscopic investigation on results of mechanical preparation of root canals. Oral Surg 1968;25:108-16.
3. Shih M, Marshall F J, Rosen S. The bactericidal efficiency of sodium hypochlorite as an endodontic irrigant. Oral Surg 1970;29:613-9.
Internal Resorption Treatment 319
4. Senia ES, Marshall F J, Rosen S. The solvent action of sodium hypochlo- rite on pulp tissue of extracted teeth. Oral Surg 1971 ;31:96-103.
5. Richman MJ. Use of ultrasonics in root canal therapy and root resections. J Dent Meal 1957;12:12-18.
6. Martin H. Ultrasonic disinfection of the root canal. Oral Surg 1976;42:92- 9.
7. Cunningham WT, Martin H, Forrest WR. Evaluation of root canal debride- ment by the endosonic ultrasonic synergistic system. Oral Surg 1982;53:401- 4.
8. Cunningham WT, Martin H. A scanning electron microscope evaluation of root canal debridement with the endosonic ultrasonic synergistic system. Oral Surg 1982;53:527-31.
9. Weine FS. Endodontic therapy. 3rd ed. St. Louis: CV Mosby, 1982. 10. Yee FS, Marlin J, Krakow AA, Gron P. 3-dimensional obturation of the
root canal using injection-molded thermoplasticized dental gutta-percha. J Endedon 1977;3:168.
11. Torabinejad M, Skobe Z, Trombly PL, Krakow hA, Gron P, Marlin J. Scanning electron microscopic study on root canal obturation using thermo- plasticized gutta-percha. J Endedon 1978;4:245.
12. Marlin J, Krakow AA, Desilets RP, Gron P. Clinical use of injection- molded thermoplasticized gutta-percha for obturation of the root canal system: a preliminary report. J Endedon 1981 ;7:277.
14. Chivian N. Root resorption. In: Cohen S, Bums RC, eds. Pathways of the pulp. St. Louis: CV Mosby Co., 1984.
15. Cunningham WT, Balekjian BA. Effect of temperature on collagen- dissolving ability of sodium hypochlodte endodontic irrigant. Oral Surg 1980;49:175-7.
16. Coffee KP, Brilliant JD. The effect of serial preparation on tissue removal on the root canals of extracted mandibular human molars. J Endodon 1975;1:211-4.
17. Goodman A, Reader A, Beck M, Melfi R, Meyers W. An in vitro comparison of the efficacy of the step-back technique versus a step-back/ ultrasonic technique in human mandibular molars. J Endedon 1985;11:249-56.
